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Intensive care unit mortality trends in children after hematopoietic stem cell transplantation: a meta-regression
Josephus P J van Gestel1, Casper W Bollen, Ingeborg van der Tweel
1Department of Pediatrics, the Pediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands. j.vangestel@umcutrecht.nl
Insights
Pediatric intensive care unit (ICU) mortality after hematopoietic stem cell transplantation (HSCT) has not clearly decreased. Patient characteristics changed, making survival improvements less evident. Further research is needed to confirm true survival gains.
Area of Science:
- Pediatric Hematology
- Critical Care Medicine
- Transplantation Science
Background:
- Ongoing debate exists regarding trends in pediatric intensive care unit (ICU) mortality following hematopoietic stem cell transplantation (HSCT).
- Assessing changes in ICU survival rates over time is crucial for understanding treatment efficacy and patient outcomes.
Purpose of the Study:
- To analyze intensive care unit (ICU) mortality trends in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT).
- To identify factors influencing ICU mortality in this vulnerable patient population.
Main Methods:
- A comprehensive literature search was conducted across MEDLINE, EMBASE, and Cochrane databases, supplemented by manual reference list reviews.
- Prospective and retrospective cohort studies reporting ICU mortality data for pediatric HSCT patients were included.
- Meta-regression analysis was employed to assess mortality trends and the impact of prognostic factors over time.
Main Results:
- Twenty-three studies encompassing 1101 ICU admissions were analyzed, revealing an overall ICU mortality of 60%.
- Mechanical ventilation, required in 822 patients, was associated with a 71% ICU mortality rate.
- While univariable analysis suggested a decrease in mortality over time, multivariable analysis indicated that only pulmonary disease remained a significant predictor of mortality, with the association between year of inclusion and mortality being less pronounced.
Conclusions:
- The widely perceived decrease in pediatric ICU mortality post-HSCT is not clearly supported by current evidence when accounting for changes in patient characteristics.
- An improvement in ICU survival is less evident after adjusting for factors like pulmonary disease and mechanical ventilation needs.
- Further research is necessary to definitively confirm any true improvement in ICU survival rates for children after HSCT.
Background:
There is ongoing discussion whether intensive care unit mortality has decreased over time for children after hematopoietic stem cell transplantation.
Objective:
To analyze intensive care unit mortality trends in children after hematopoietic stem cell transplantation.
Data Sources:
Search of MEDLINE, EMBASE, and Cochrane databases, and a manual review of reference lists.
Study Selection:
Prospective and retrospective cohort studies containing intensive care unit mortality data of children after hematopoietic stem cell transplantation.
Data Extraction:
Mortality statistics and features associated with mortality were abstracted from studies of interest. To assess mortality over time, the median years of inclusion in original studies were included as risk factor. A multiple random-effects meta-regression analysis was conducted to assess the independent contribution of prognostic factors on mortality.
Data Synthesis:
Twenty-three studies were included, reporting on 1101 intensive care unit admissions. Overall intensive care unit mortality was 60% (range, 25%-91%). Once mechanical ventilation was necessary (n = 822), mean intensive care unit mortality was 71% (range, 25%-91%). Over the years, significantly fewer intensive care unit admitted patients received mechanical ventilation (p < 0.001). Univariable analysis in all intensive care unit admitted patients showed a significant decrease in mortality associated with year of inclusion. Mechanical ventilation and pulmonary disease were associated with increased mortality. In the multiple meta-regression analysis, only pulmonary disease remained significantly associated with mortality (odds ratio = 1.21, 95% confidence interval 1.01-1.46 per 10% increase in the number of patients with pulmonary disease in studies). The association between year of inclusion and intensive care unit mortality was less pronounced (odds ratio = 0.92, 95% confidence interval 0.84-1.01).
Conclusion:
There is a widely held impression that intensive care unit mortality clearly decreased in children after hematopoietic stem cell transplantation. However, characteristics of intensive care unit admitted patients significantly changed over time. After correcting for this, an improvement in intensive care unit survival was less evident. More studies are needed before a true improvement in intensive care unit survival can be confirmed.
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